Coding and Billing Guidelines - Centers for Medicare ...

1 1 Coding and Billing Guidelines *Psychiatry and Psychology Services PSYCH-014 - L30489 Contractor Name Wisconsin Physicians Service (WPS) Contractor Number 00951, 00952, 00953, 00954 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402, 52280 Contractor Type Carrier Fiscal Intermediary A MAC A MAC B Effective Date: 03/18/2010 I. General Coding Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. References to providers include physicians and non-physicians, such as clinical psychologists, independent psychologists, nurse practitioners, clinical nurse specialists and physician assistances when the services performed are within the scope of their state license and clinical practice/education.

2 Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. Psychiatric service CPT codes should not be used when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes is more appropriate. CMS National Coverage Policy: Section 1833(c) of the Social Security Act. Section 1861(s)(2)(C) of the Social Security Act Section 1861(s)(3) of the Social Security Act Section 1842(b)(2)(A) of the Social Security Act Chapter 15, of the Benefits Policy Manual, Pub. 100-02 Transmittal: 55 Chapter 15, of the Benefits Policy Manual, Pub. 100-02 Transmittal: 85 Chapter 15, section 160 of the Benefits Policy Manual, Pub. 100-02. Chapter 15, section 200 of the Benefits Policy Manual, Pub.

3 100-02. Chapter 15, section 210 of the Benefits Policy Manual, Pub. 100-02. Chapter 15, section 190 of the Benefits Policy Manual, Pub. 100-02. Final physician fee schedule regulation at 70 FR 70279 and 70280 under Table 29: AMA, RUC and HCPAC Recommendations and CMS Decisions for New and Revised 2006 CPT Codes A. Psychiatry and Psychology Services: Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. These CPT codes should not be used as generic psychiatric service 2 CPT codes when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.

4 Family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient s condition. Examples include: 1. When there is a need to observe and correct, through psychotherapeutic techniques, the patient s interaction with family members (CPT code 90847); and/or 2. Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient (90846 or 90847).. CPT code 90849 represents multiple-family group psychotherapy and would generally be non-covered by Medicare . Such group therapy is directed to the effects of the patient s condition on the family, and does not meet Medicare s standards of being part of the provider personal services to the patient.

5 Claims for 90849 may be approved on and individual consideration basis. CMS Publication 100-03; Medicare National Coverage Determinations Manual, Chapter 1, Psychiatric services must be performed by a qualified health care provider. See PSYCH-013 for incident to psychiatric services Guidelines . B. Psychological Testing and Neuropsychological Testing Psychiatric tests and Neuropsychological tests are diagnostic procedures and therefore incident to provisions do not apply. The person described in the CPT code must perform the psychiatric test. The time spend on the interpretation and report performed by a technician or computer must be billed using an appropriate CPT code and may not be added to any other CPT code . Under the diagnostic tests provision, all diagnostic tests are assigned a certain level of supervision.

6 Generally, regulations governing the diagnostic tests provision require that only physicians can provide the assigned level of supervision for diagnostic tests. However, there is a regulatory exception to the supervision requirement for diagnostic psychological and neuropsychological tests in terms of who can provide the supervision. That is, regulations allow a clinical psychologist (CP) or a physician to perform the general supervision assigned to diagnostic psychological and neuropsychological tests. In addition, nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP.

7 Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit instead of the requirements for diagnostic psychological and neuropsychological tests. Accordingly, NPs and CNSs must perform tests in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a physician. PAs perform tests under the general supervision of a physician as required for services furnished under the PA benefit. Furthermore, physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill three test codes as sometimes therapy codes. Specifically, CPT codes 96105, 96110 and 96111 may be performed by these therapists. 3 However, when PTs, OTs and SLPs perform these three tests, they must be performed under the general supervision of a physician or a CP.

8 Who May Bill for Diagnostic Psychological and Neuropsychological Tests CPs see qualifications under chapter 15, section 160 of the Benefits Policy Manual, Pub. 100-02. NPs to the extent authorized under State scope of practice. See qualifications under chapter 15, section 200 of the Benefits Policy Manual, Pub. 100-02. CNSs to the extent authorized under State scope of practice. See qualifications under chapter 15, section 210 of the Benefits Policy Manual, Pub. 100-02. PAs to the extent authorized under State scope of practice. See qualifications under chapter 15, section 190 of the Benefits Policy Manual, Pub. 100-02. Independently Practicing Psychologists (IPPs), agency, or physician s office are covered when a physician orders such tests.

9 PTs, OTs and SLPs see qualifications under chapter 15, sections of the Benefits Policy Manual, Pub. 100-02. Physical therapists (PTs), occupational therapists (OTs) and speech language pathologists (SLPs) are authorized to bill three test codes as sometimes therapy codes. Specifically, CPT codes 96105, 96110 and 96111 may be performed by these therapists. However, when PTs, OTs and SLPs perform these three tests, they must be performed under the general supervision of a physician or a CP. CPT code 96125 is used by OTs or SLP. Other providers should use the appropriate code CPT code from the 96101-96103 or 96118-96120. NOTE: Independent Psychologist When diagnostic psychological tests are performed by a psychologist who is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the psychological tests.

10 Psychologists are considered to be practicing independently when they render services on their own responsibility, free of the administrative and professional control of an employer such as a physician, institution or agency; the persons they treat are their own patients; and they have the right to bill directly, collect and retain the fee for their services. II. Service-specific Guidelines : A. Psychiatric Diagnostic Interview Examination (CPT code 90801): An E/M service may be substituted for the initial interview procedure, including consultation CPT codes, (CPT codes 99241-99263), provided required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice.